Provider Demographics
NPI:1538174172
Name:PRESTONSBURG PHARMACIST GROUP LLC
Entity type:Organization
Organization Name:PRESTONSBURG PHARMACIST GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-370-4336
Mailing Address - Street 1:1002 SOUTH BROADWAY
Mailing Address - Street 2:SUITE 7
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324
Mailing Address - Country:US
Mailing Address - Phone:502-370-4336
Mailing Address - Fax:502-370-4352
Practice Address - Street 1:400 UNIVERSITY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653
Practice Address - Country:US
Practice Address - Phone:606-886-1202
Practice Address - Fax:606-886-1346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTONSBURG PHARMACIST GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
KYP016623336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2030532OtherPK
KY54019179Medicaid
4703030001Medicare NSC